Quality of inpatient paediatric and newborn care in district hospitals
Authors: Moise Muzigaba, Theresa Diaz, Blerta Maliqi, Wilson Were, Kathleen Strong, Tamar Chitashvili, Allysha Choudhury, Debra Jackson, Anne Detjen, Jennifer Requejo, Emma Sacks, Anshu Banerjee
Journal: The Lancet Global Health (2023)

We read with great interest the Viewpoint by Mike English and colleagues on the quality of care for paediatric and newborn patients in district hospitals, published in The Lancet Global Health.1English M Aluvaala J Maina M Duke T Irimu G Quality of inpatient paediatric and newborn care in district hospitals: WHO indicators, measurement, and improvement.Lancet Glob Health. 2023; 11: e1114-e1119Summary Full Text Full Text PDF PubMed Scopus (3) Google Scholar The authors focus, in part, on WHO recommendations for measuring paediatric quality of care and small and sick newborn quality of care in health facilities. They report that WHO has published more than 1000 non-prescriptive quality of care indicators to meet measurement needs of key actors and argue that "when presented with such a huge array of indicators, key actors could either feel overwhelmed (and avoid engaging in the quality agenda) or feel under pressure to perform seemingly impossible measurement tasks". Authors also conclude that presenting multiple indicators to country-level actors bears the "risk of narrowing the gaze of quality improvement to only measuring indicators without implementing subsequent improvement actions". In the broader view, the Viewpoint by English and colleagues provides valid and important insights about paediatric quality of care measurement and improvement challenges in low-income and middle-income countries, including workforce shortages, data fragmentation, and data quality issues. It also rightfully notes varying data needs at different levels; the importance of quality measurement across the care continuum, service delivery levels, and system categories; the need for better integration of quality of care indicators into routine health information systems; the importance of collaborative consensus building process around quality of care measurement; and governance and accountability. Furthermore, the Viewpoint clearly highlights the primary objective of care quality measurement: to inform improvement actions at all levels. However, the authors' interpretation of illustrative measures of quality of paediatric care and small and sick newborn care, outlined in the respective WHO quality of care standards, is incomplete and could be misleading to the public. The authors' argument is largely centred around a suite of 1098 "quality measures" (and not indicators per se, because WHO has not defined all of them as such nor developed associated metadata) that WHO published as a component of the standards for improving quality of care for paediatric and young adolescent health in health facilities (n=520),2WHOStandards for improving the quality of care for children and young adolescents in health facilities.https://www.who.int/publications/i/item/9789241565554Date: April 11, 2018Date accessed: June 4, 2023Google Scholar and for improving quality of care for small and sick newborns in health facilities (n=578).3WHOStandards for improving quality of care for small and sick newborns in health facilities.https://www.who.int/publications/i/item/9789240010765Date: Sept 2, 2020Date accessed: June 4, 2023Google Scholar These measures are linked to quality of care standards, and, as the authors acknowledge, they constitute a catalogue of non-prescriptive and not all-inclusive measures from which quality improvement teams can choose and develop indicators and related metadata to monitor their efforts. The use of such measures is intended to be selective based on the priorities at national, subnational, or health-facility levels, or for a specific quality improvement project. Therefore, their use should be time-delimited depending on the duration of these initiatives, thereby posing minimal measurement burden to the users. In fact, the rationale, purpose, intended users, and level of use for these and other types of indicators recommended by WHO are explained in a WHO publication which outlines four quality of care measurement components recommended by WHO.4Maternal, Newborn, Child & Adolescent Health & AgeingQuality of Care NetworkQuality of care for maternal and newborn health – a monitoring framework for network countries.https://www.who.int/publications/m/item/quality-of-care-for-maternal-and-newborn--a-monitoring-framework-for-network-countriesDate: Feb 27, 2019Date accessed: July 12, 2023Google Scholar These key measurement components are summarised in the figure. Unfortunately, English and colleagues did not cite this important resource that more accurately and comprehensively represents WHO's recommendations. They argue that using "a small number of carefully measured quality indicators might be the best initial strategy". We agree that a standardised set of high-quality, well defined indicators is essential. WHO, in fact, recommends a small set of 25 core paediatric and young adolescent quality of care indicators that were published in 2022, along with the methodology that was used to generate them.5Muzigaba M Chitashvili T Choudhury A et al.Global core indicators for measuring WHO's paediatric quality-of-care standards in health facilities: development and expert consensus.BMC Health Serv Res. 2022; 22: 887Crossref PubMed Scopus (2) Google Scholar A similar set of global core indicators for measuring small and sick newborn quality of care will also be published soon by WHO. For all quality of care standards that WHO publishes, there is a set of core indicators that are developed and recommended in turn for use at the country level. WHO is working towards ensuring that all member states, partners, other UN agencies, and academic institutions have access to recommended indicators for child health, including detailed metadata through Child Health Accountability Tracking6WHOThe network for improving quality of care for maternal, newborn and child health: evolution, implementation, and progress: 2017-2020 report.https://www.who.int/publications/i/item/9789240023741Date: May 5, 2021Date accessed: July 12, 2023Google Scholar and an online indicator toolkit which will be expanded to include core quality of care indicators. A new internal WHO working group on indicator governance has also been created to better define indicator standards and ensure standardisation of metadata across the entire organisation. We welcome feedback from the broader scientific community and the users of WHO technical products as part of iterative improvement of our normative guidance; however, our position on this Viewpoint is that it misrepresents WHO's current recommendations, and mischaracterises WHO's ongoing work, and should, as such, be revised to provide more accurate information for the quality of care measurement practice. The current WHO recommendations on quality of care measurement have been made in conjunction with a wide range of experts in the global public health community. Understanding the recommendations and especially the four components of maternal, newborn, and child health quality of care measurement is important to improve care quality in health facilities. MM, TD, BM, WW, KS, and AB are employees of WHO. MM, TC, AC, WW, TD, KS, DJ, JR, AD, and ES are authors of one of the cited articles in which the WHO core set of paediatric and young adolescent quality of care indicators were published. Quality of inpatient paediatric and newborn care in district hospitals: WHO indicators, measurement, and improvementPoor-quality paediatric and neonatal care in district hospitals in low-income and middle-income countries (LMICs) was first highlighted more than 20 years ago. WHO recently developed more than 1000 paediatric and neonatal quality indicators for hospitals. Prioritising these indicators should account for the challenges in producing reliable process and outcome data in these settings, and their measurement should not unduly narrow the focus of global and national actors to reports of measured indicators. Full-Text PDF Open AccessQuality of inpatient paediatric and newborn care in district hospitals – Authors' replyWe are grateful to Moise Muzigaba and colleagues for their comments on our recent Viewpoint.1 We have a shared aim of improving the quality of facility-based care, and discussing how to achieve this goal is important so that all stakeholders can be supported in this challenge. We acknowledge that we referred to 1098 paediatric and neonatal quality indicators rather than quality measures and that WHO has undertaken rigorous work to develop a flexible set of prioritised indicators, including the work of Muzigaba and colleagues to produce 25 core paediatric indicators from 520 paediatric quality measures. Full-Text PDF Open Access